Partial Fix for Unexpected Colonoscopy Charges

Some people who go in for a routine screening colonoscopy (fully covered by most insurance) can end up with a surprise bill of several hundred dollars, if the doctor detected and removed one or more polyps.

Under current law, Medicare beneficiaries must pay a coinsurance when their screening colonoscopy also involves the removal of polyps or other tissue—because it is reclassified as a “treatment” procedure. Additionally, while current law also requires most private payers to cover colorectal cancer screenings without cost-sharing (copays/ coinsurance/ deductible), private payers have interpreted the rules differently. Some private payers waive cost- sharing when a screening involves the removal of polyps or other tissue; others do not.

Two weeks ago, we scored a partial victory. The Department of Health and Human Services issued a regulation change stating that private insurance companies cannot charge patients for the removal of a polyp during a screening colonoscopy. The HHS ruling this week was a result of a very productive meeting that we had at HHS last summer with a cooperative group of patient advocacy organizations and professional doctors’ associations.

This is progress, but this ruling doesn’t fix the Medicare policy—yet.

This is what Fight Colorectal Cancer does: Fight for you

For those of you who are new to Fight Colorectal Cancer, you’ll quickly learn that one of our strengths is being a respected, well-known voice in Congress and key federal agencies (e.g., National Cancer Institute, the FDA, Centers for Medicare and Medicaid Services, Dept. of Defense). Our staff and advocates monitor events 24/7 and work behind the scenes—often for months or years–on tedious details and complex issues with the decision makers. We’ve been partnering with other organizations since 2012 on this particular, knotty problem.

In last year’s Congress, Fight Colorectal Cancer was instrumental in the introduction of legislation in the House (H.R. 4120) that would correct Medicare law, and has lobbied the Department of HHS for a change in regulation.

We are working with our congressional allies to see if this HHS ruling may somehow spur the Medicare fix, while also continuing to work toward the reintroduction of a House bill (and a Senate bill) to get the job done in the 113th Congress.

As soon as we get new House and Senate bill numbers for this year, we’ll issue an Action Alert here so you can begin lobbying your congressional representatives.

What this means for patients:

If you have private insurance, have a routine screening colonoscopy (not ordered to check out symptoms, or as a result of a positive stool blood test); and have precancerous polyps removed, your insurer cannot charge a copayment. (The HHS has ruled that removing precancerous polyps is an “integral part of a colonoscopy.” Under the Affordable Care Act, no copays can be charged for approved screening tests.)

If you have private insurance, and your doctor determines that you are in a high-risk category (e.g., you have a family history of colorectal cancer) that is covered by screening guidelines, the same rules apply: No copayment for a screening colonoscopy that includes removal of precancerous polyps.

If you have Medicare coverage, you may still be charged a copayment if a screening colonoscopy includes removal of a polyp.

If you have either private or Medicare coverage, it appears that a followup colonoscopy ordered because of a positive FOBT (stool test for blood) is not considered a screening procedure, and is not covered by this rule change.

Yes, it’s complicated. If you have questions or concerns, please call our Answer Line at 1-877-427-2111.